The influence of the Gyne-T 380S IUD on menstrual blood loss and iron status

U.S. Selected Practice Recommendations for Contraceptive Use, 2024

The 2024 U.S. Selected Practice Recommendations for Contraceptive Use (U.S. SPR) addresses a selected group of common, yet sometimes complex, issues regarding initiation and use of specific contraceptive methods. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. SPR (CDC. U.S. Selected Practice Recommendations for Contraceptive Use, 2016. MMWR 2016;65[No. RR-4]:1-66). Notable updates include 1) updated recommendations for provision of medications for intrauterine device placement, 2) updated recommendations for bleeding irregularities during implant use, 3) new recommendations for testosterone use and risk for pregnancy, and 4) new recommendations for self-administration of injectable contraception. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Contraception in Adolescents

Adolescents are at risk for unwanted pregnancy when they become sexually active, and contraception is an important part of mitigating this risk. Use of contraceptive methods, and long-acting reversible contraceptive methods such as implants and intrauterine devices in particular, has increased among adolescents. Although sexual activity has declined and contraceptive use has increased among adolescents in the United States in recent years, the unintended pregnancy rate remains high. All of the currently available contraceptive methods are safe and effective for adolescents to use; however, adolescents may have specific concerns about side effect profiles and unscheduled bleeding that should be addressed during contraceptive counseling. Healthcare providers should prioritize adolescents' needs and preferences when approaching contraceptive counseling, and also consider the unique access and confidentiality issues that adolescents face when accessing contraception.

Contraception across the transmasculine spectrum

The field of transgender health continues to expand rapidly, including research in the area of family planning. While much attention has been given to fertility preservation and the parenting intentions of transgender individuals, far less has been paid to pregnancy prevention and contraceptive needs of people along the transmasculine gender spectrum (transgender men and gender-nonbinary persons who were assigned female at birth). Existing research illustrates that many clinicians and transmasculine individuals falsely believe that there is no risk of pregnancy while amenorrheic. These studies also show inconsistent counseling practices provided to transmasculine persons surrounding contraception and pregnancy while falling short of providing robust clinical guidance for improvement. Clinicians report a lack of adequate training in transgender reproductive health, and consequently, many do not feel comfortable treating transgender patients. The aim of this publication is to consolidate the findings of these prior studies and build upon them to offer comprehensive clinical guidance for managing contraception in transmasculine patients. To do so, it reviews the physiologic effects of testosterone on the sex steroid axis and current understanding of why ovulation and pregnancy may still occur while amenorrheic. Gender-inclusive terminology and a suggested script for eliciting a gender-affirming sexual history are offered. Common concerns (such as the effects on gender dysphoria and gender affirmation) and side effects of available contraceptive methods are subsequently addressed and how these may have a unique impact on transmasculine persons as compared with cisgender women. Lastly, a model is provided for approaching contraceptive counseling in the transmasculine population to assist clinicians and patients in determining the need for and selection of the type of contraception. To center transmasculine voices, the development of this publication's guidelines have been led by reproductive care clinicians of transgender experience.

[Intrauterine contraception: CNGOF Contraception Guidelines]

OBJECTIVE

To provide national clinical guidelines focusing on intrauterine contraception.

METHODS

A systematic review of available literature was performed using Pubmed and Cochrane libraries. American, British and Canadian guidelines were considered as well.

RESULTS

Intrauterine contraception (IUC) displays a wide panel of indications, including adolescents, nulliparous, patients living with HIV before AIDS (Grade B) and women with history of ectopic pregnancy (Grade C). Cervical cancer screening should not be modified in women with IUC (Grade B). Bimanual examination and cervix inspection are mandatory before device insertion (Grade B). Patients should not systematically undergo screening for sexually transmitted infections (STI) before device insertion (Grade B). Screening for STI should be preferably done before insertion but it can be performed at the time of device insertion in asymptomatic women (Grade B). Routine antibiotic prophylaxis and premedication are not recommended before insertion (Grade A). A follow-up visit may be offered several weeks after insertion (Professional consensus). Routine pelvic ultrasound examination in not recommended after device insertion (Grade B). In patients with IUC, unscheduled bleeding, when persistent or associated with pelvic pain, requires further investigation to rule out complication (Professional agreement). Suspected uterine perforation warrants radiological workup to locate the device (Professional consensus). Laparoscopic approach should be preferred for elective removal of intrauterine device from abdominal cavity (Professional consensus). In case of accidental pregnancy with intrauterine device in situ, ectopic pregnancy should be excluded (Grade B). In case of viable and desired intrauterine pregnancy, intrauterine device removal is recommended if the strings are reachable (Grade C). Detection of Actinomyces-like organisms on pap smear in asymptomatic patients with intrauterine contraception does not require further intervention (Grade B). Immediate removal of intrauterine device is not recommended in case of STI or pelvic inflammatory disease (Grade B). Device removal should be considered in the absence of clinical improvement after 48 to 72 hours of appropriate treatment (Grade B).

CONCLUSION

Intrauterine contraception is a long-acting and reversible contraception method displaying great efficacy and high continuation rate. In contrast, complication rate is low. It should thus be offered to both nulliparous and multiparous women.

Dimensional analysis of the endometrial cavity: how many dimensions should the ideal intrauterine device or system have?

Background

The geometrical shape of the human uterus most closely approximates that of a prolate ellipsoid. The endometrial cavity itself is more likely to also have the shape of a prolate ellipsoid especially when the extension of the cervix is omitted. Using this information and known endometrial cavity volumes and lateral and vertical dimensions, it is possible to calculate the anteroposterior (AP) dimensions and get a complete evaluation of all possible dimensions of the endometrial cavity. These are singular observations and not part of any other study.

Methods

The AP dimensions of the endometrial cavity of the uterus were calculated using the formula for the volume of the prolate ellipsoid to complete a three-dimensional picture of the endometrial cavity.

Results

Calculations confirm ultrasound imaging which shows large variations in cavity size and shape. Known cavity volumes and length and breadth measurements indicate that the AP diameter may vary from 6.29 to 38.2 mm. These measurements confirm the difficulty of getting a fixed-frame intrauterine device (IUD) to accommodate to a space of highly variable dimensions. This is especially true of three-dimension IUDs. A one-dimensional frameless IUD is most likely to be able to conform to this highly variable space and shape.

Conclusion

The endometrial cavity may assume many varied prolate ellipsoid configurations where one or more measurements may be too small to accommodate standard IUDs. A one-dimensional device is most likely to be able to be accommodated by most uterine cavities as compared to two- and three-dimensional devices.

LNG-IUS 12: a 19.5 levonorgestrel-releasing intrauterine system for prevention of pregnancy for up to five years

INTRODUCTION

Globally, intrauterine devices (IUDs) are the second most commonly used form of reversible contraception because of their high efficacy, safety, convenience and cost effectiveness. The levonorgestrel releasing intrauterine system with daily average release of 20 mcg (LNG-IUS 20) is the popular choice because of its favorable bleeding patterns and many noncontraceptive benefits. A three year (LNG-IUS 8) became available three years ago. More recently, the LNG-IUS 12 was added. This new IUD shares a smaller frame, narrow inserter and lower rate of amenorrhea with the LNG-IUS 8, but it offers the five years of contraceptive protection of the LNG-IUS 20. Areas covered: This article provides information on the contraceptive efficacy, safety and tolerability of this new IUS based on approximately 60,000 cycles of use. Where available, the impacts of subject age, parity and body mass index (BMI) on study outcomes are reported. Expert opinion: This new LNG-IUS 12 with mid-dose hormone levels, smaller frame and longer effective life fills a niche that may better meet the needs of women who might appreciate the narrow insertion tube and/or the lower rates of amenorrhea. Cost will ultimately help determine success.

Providing Contraception to Adolescents

Adolescents have high rates of unintended pregnancy and face unique reproductive health challenges. Providing confidential contraceptive services to adolescents is important in reducing the rate of unintended pregnancy. Long-acting contraception such as the intrauterine device and contraceptive implant are recommended as first-line contraceptives for adolescents because they are highly effective with few side effects. The use of barrier methods to prevent sexually transmitted infections should be encouraged. Adolescents have limited knowledge of reproductive health and contraceptive options, and their sources of information are often unreliable. Access to contraception is available through a variety of resources that continue to expand.

New developments in intrauterine device use: focus on the US

Many more women in the US today rely upon intrauterine devices (IUDs) than in the past. This increased utilization may have substantially contributed to the decline in the percentage of unintended pregnancies in the US. Evidence-based practices have increased the number of women who are medically eligible for IUDs and have enabled more rapid access to the methods. Many women enjoy freedom to use IUDs without cost, but for many the impact of the Affordable Care Act has yet to be realized. Currently, there are three hormonal IUDs and one copper IUD available in the US. Each IUD is extremely effective, convenient, and safe. The newer IUDs have been tested in populations not usually included in clinical trials and provide reassuring answers to older concerns about IUD use in these women, including information about expulsion, infection, and discontinuation. On the other hand, larger surveillance studies have provided new estimates about the risks of complications such as perforation, especially in postpartum and breastfeeding women. This article summarizes significant features of each IUD and provides a summary of the differences to aid clinicians in the US and other countries in advising women about IUD choices.

Unscheduled bleeding and contraceptive choice: increasing satisfaction and continuation rates

Approximately half (51%) of the 6.6 million pregnancies in the US each year are unintended and half of those pregnancies (54%) occur among women not using contraception. Many women discontinue their contraceptives due to method dissatisfaction. Bothersome unscheduled bleeding is one of the main reasons cited by women for stopping a birth control method. Improving counseling and management of these side effects will aide in increasing satisfaction with contraceptive methods. The following review will discuss the bleeding profiles associated with the contraceptive options available in the US. A valuable resource from the Centers for Disease Control and Prevention, the US Selected Practice Recommendations for Contraceptive Use, will be introduced. Definitions of the types of unscheduled bleeding are included, as well as strategies for treatment for each contraceptive method. The evidence whether or not anticipatory counseling increases continuation rates will also be reviewed.

Intrauterine systems: a frameless future?

INTRODUCTION

Intrauterine devices (IUD) are viewed as important contraceptive methodologies to prevent unintended pregnancy.

AREAS COVERED

This expert opinion examines the place of frameless devices for use in young women in order to minimize side effect, improve patient comfort and maximize continuation of use to help reduce unintended pregnancies.

EXPERT OPINION

Frameless designed IUDs have the ability to be used in both small and large uterine cavities of varied shapes and can significantly reduce abnormal bleeding, pain, embedment and expulsion and likely account for higher continuation rates than that seen with framed IUDs.

Canadian Contraception Consensus (Part 3 of 4): Chapter 7--Intrauterine Contraception

OBJECTIVE

To provide guidelines for health care providers on the use of contraceptive methods to prevent pregnancy and on the promotion of healthy sexuality.

OUTCOMES

Overall efficacy of cited contraceptive methods, assessing reduction in pregnancy rate, safety, ease of use, and side effects; the effect of cited contraceptive methods on sexual health and general well-being; and the relative cost and availability of cited contraceptive methods in Canada.

EVIDENCE

Published literature was retrieved through searches of Medline and The Cochrane Database from January 1994 to January 2015 using appropriate controlled vocabulary (e.g., contraception, sexuality, sexual health) and key words (e.g., contraception, family planning, hormonal contraception, emergency contraception). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from January 1994 to January 2015. Searches were updated on a regular basis in incorporated in the guideline to June 2015. Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies.

VALUES

The quality of the evidence in this document was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). CHAPTER 7: INTRAUTERINE CONTRACEPTION:

SUMMARY STATEMENTS

1. Intrauterine contraceptives are as effective as permanent contraception methods. (II-2) 2. The use of levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg by patients taking tamoxifen is not associated with recurrence of breast cancer. (I) 3. Intrauterine contraceptives have a number of noncontraceptive benefits. The levonorgestrel-releasing intrauterine system (LNG-IUS) 52 mg significantly decreases menstrual blood loss (I) and dysmenorrhea. (II-2) Both the copper intrauterine device and the LNG-IUS significantly decrease the risk of endometrial cancer. (II-2) 4. The risk of uterine perforation decreases with inserter experience but is higher in postpartum and breastfeeding women. (II-2) 5. The risk of pelvic inflammatory disease (PID) is increased slightly in the first month after intrauterine contraceptive (IUC) insertion, but the absolute risk is low. Exposure to sexually transmitted infections and not the IUC itself is responsible for PID occurring after the first month of use. (II-2) 6. Nulliparity is not associated with an increased risk of intrauterine contraceptive expulsion. (II-2) 7. Ectopic pregnancy with an intrauterine contraceptive (IUC) is rare, but when a pregnancy occurs with an IUC in situ, it is an ectopic pregnancy in 15% to 50% of the cases. (II-2) 8. In women who conceive with an intrauterine contraceptive (IUC) in place, early IUC removal improves outcomes but does not entirely eliminate risks. (II-2) 9. Intrauterine contraceptives do not increase the risk of infertility. (II-2) 10. Immediate insertion of an intrauterine contraceptive (10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher continuation rate compared with insertion at 6 weeks postpartum. (I) 11. Immediate insertion of an intrauterine contraceptive (IUC; 10 minutes postplacental to 48 hours) postpartum or post-Caesarean section is associated with a higher risk of expulsion. (I) The benefit of inserting an IUC immediately postpartum or post-Caesarean section outweighs the disadvantages of increased risk of perforation and expulsion. (II-C) 12. Insertion of an intrauterine contraceptive in breastfeeding women is associated with a higher risk of uterine perforation in the first postpartum year. (II-2) 13. Immediate insertion of an intrauterine contraceptive (IUC) post-abortion significantly reduces the risk of repeat abortion (II-2) and increases IUC continuation rates at 6 months. (I) 14. Antibiotic prophylaxis for intrauterine contraceptive insertion does not significantly reduce postinsertion pelvic infection. (I) RECOMMENDATIONS: 1. Health care professionals should be careful not to restrict access to intrauterine contraceptives (IUC) owing to theoretical or unproven risks. (III-A) Health care professionals should offer IUCs as a first-line method of contraception to both nulliparous and multiparous women. (II-2A) 2. In women seeking intrauterine contraception (IUC) and presenting with heavy menstrual bleeding and/or dysmenorrhea, health care professionals should consider the use of the levonorgestrel intrauterine system 52 mg over other IUCs. (I-A) 3. Patients with breast cancer taking tamoxifen may consider a levonorgestrel-releasing intrauterine system 52 mg after consultation with their oncologist. (I-A) 4. Women requesting a levonorgestrel-releasing intrauterine system or a copper-intrauterine device should be counseled regarding changes in bleeding patterns, sexually transmitted infection risk, and duration of use. (III-A) 5. A health care professional should be reasonably certain that the woman is not pregnant prior to inserting an intrauterine contraceptive at any time during the menstrual cycle. (III-A) 6. Health care providers should consider inserting an intrauterine contraceptive immediately after an induced abortion rather than waiting for an interval insertion. (I-B) 7. In women who conceive with an intrauterine contraceptive (IUC) in place, the diagnosis of ectopic pregnancy should be excluded as arly as possible. (II-2A) Once an ectopic pregnancy has been excluded, the IUC should be removed without an invasive procedure. The IUC may be removed at the time of a surgical termination. (II-2B) 8. In the case of pelvic inflammatory disease, it is not necessary to remove the intrauterine contraceptive unless there is no clinical improvement after 48 to 72 hours of appropriate antibiotic treatment. (II-2B) 9. Routine antibiotic prophylaxis for intrauterine contraceptive (IUC) insertion is not indicated. (I-B) Health care providers should perform sexually transmitted infection (STI) testing in women at high risk of STI at the time of IUC insertion. If the test is positive for chlamydia and/or gonorrhea, the woman should be appropriately treated postinsertion and the IUC can remain in situ. (II-2B) 10. Unscheduled bleeding in intrauterine contraception users, when persistent or associated with pelvic pain, should be investigated to rule out infection, pregnancy, gynecological pathology, expulsion or malposition. (III-A)

Permanent contraception for women

Permanent methods of contraception are used by an estimated 220 million couples worldwide, and are often selected due to convenience, ease of use and lack of side effects. A variety of tubal occlusion techniques are available for female permanent contraception, and procedures can be performed using a transcervical or transabdominal approach. This article reviews currently available techniques for female permanent contraception and discusses considerations when helping patients choose a contraceptive method and tubal occlusion technique.

Association of short-term bleeding and cramping patterns with long-acting reversible contraceptive method satisfaction

OBJECTIVE

We sought to examine the short-term (3- and 6-month), self-reported bleeding and cramping patterns with intrauterine devices (IUDs) and the contraceptive implant, and the association of these symptoms with method satisfaction.

STUDY DESIGN

We analyzed 3- and 6-month survey data from IUD and implant users in the Contraceptive CHOICE Project, a prospective cohort study. Participants who received a long-acting reversible contraceptive (LARC) method (levonorgestrel-releasing intrauterine system [LNG-IUS], copper IUD, or the etonogestrel implant) and completed their 3- and 6-month surveys were included. Univariable and multivariable analyses were performed to examine the association of bleeding and cramping patterns with short-term satisfaction.

RESULTS

Our analytic sample included 5011 Contraceptive CHOICE Project participants: 3001 LNG-IUS users, 826 copper IUD users, and 1184 implant users. At 3 months, >65% of LNG-IUS and implant users reported no change or decreased cramping, while 63% of copper IUD users reported increased menstrual cramping. Lighter bleeding was reported by 67% of LNG-IUS users, 58% of implant users, and 8% of copper IUD users. Satisfaction of all LARC methods was high (≥90%). LARC users with increased menstrual cramping (relative risk adjusted [RRadj], 0.78; 95% confidence interval [CI], 0.72-0.85), heavier bleeding (RRadj, 0.83; 95% CI, 0.76-0.92), and increased bleeding frequency (RRadj, 0.73; 95% CI, 0.67-0.80) were less likely to report being very satisfied at 6 months.

CONCLUSION

Regardless of the LARC method, satisfaction at 3 and 6 months is very high. Changes in self-reported bleeding and cramping are associated with short-term LARC satisfaction.

Intrauterine devices and endometrial cancer risk: a pooled analysis of the Epidemiology of Endometrial Cancer Consortium

Intrauterine devices (IUDs), long-acting and reversible contraceptives, induce a number of immunological and biochemical changes in the uterine environment that could affect endometrial cancer (EC) risk. We addressed this relationship through a pooled analysis of data collected in the Epidemiology of Endometrial Cancer Consortium. We combined individual-level data from 4 cohort and 14 case-control studies, in total 8,801 EC cases and 15,357 controls. Using multivariable logistic regression, we estimated pooled odds ratios (pooled-ORs) and 95% confidence intervals (CIs) for EC risk associated with ever use, type of device, ages at first and last use, duration of use and time since last use, stratified by study and adjusted for confounders. Ever use of IUDs was inversely related to EC risk (pooled-OR = 0.81, 95% CI = 0.74-0.90). Compared with never use, reduced risk of EC was observed for inert IUDs (pooled-OR = 0.69, 95% CI = 0.58-0.82), older age at first use (≥ 35 years pooled-OR = 0.53, 95% CI = 0.43-0.67), older age at last use (≥ 45 years pooled-OR = 0.60, 95% CI = 0.50-0.72), longer duration of use (≥ 10 years pooled-OR = 0.61, 95% CI = 0.52-0.71) and recent use (within 1 year of study entry pooled-OR = 0.39, 95% CI = 0.30-0.49). Future studies are needed to assess the respective roles of detection biases and biologic effects related to foreign body responses in the endometrium, heavier bleeding (and increased clearance of carcinogenic cells) and localized hormonal changes.

Myths and misconceptions about long-acting reversible contraception (LARC)

PURPOSE

To discuss common myths and misconceptions about long-acting reversible contraception (LARC) among patients and health care providers.

METHODS

We address some of these common myths in an effort to provide clinicians with accurate information to discuss options with patients, parents, and referring providers. The list of myths was created through an informal survey of an online listserv of 200 family planning experts and from the experiences of the authors.

RESULTS

When presented with information about LARC, adolescents are more likely to request LARC and are satisfied with LARC. Clinicians have an important role in counseling about and providing LARC to their adolescent patients as well as supporting them in managing associated side effects.

CONCLUSIONS

This review article can be used as a resource for contraceptive counseling visits and for the continuing education of health professionals providing adolescent reproductive health care.

Hemoglobin and serum ferritin levels in women using copper-releasing or levonorgestrel-releasing intrauterine devices: a systematic review

BACKGROUND

The use of intrauterine devices as a contraceptive method has been steadily growing in developing countries. Anemia in reproductive-age women is a growing concern in those settings.

STUDY DESIGN

A systematic review of studies with measured hemoglobin and serum ferritin at baseline and after 1 year of use of copper intrauterine devices (IUDs) or a levonorgestrel-releasing intrauterine system (LNG IUS) was performed.

RESULTS

Fourteen studies involving copper IUDs in nonanemic women and 4 studies in anemic women and 6 involving the LNG IUS met the criteria for the systematic review. Meta-analyses for hemoglobin changes showed significant decreases for users of copper IUDs and an increase for the LNG IUS, but with limited data. In general, ferritin levels followed the same pattern.

CONCLUSION

Decreases in hemoglobin mean values in copper IUD users were not sufficient to induce anemia in previously nonanemic women. Women who are borderline anemic would likely benefit from using the LNG IUS.

Safety, Efficacy, and Patient Acceptability of the Copper T-380A Intrauterine Contraceptive Device

The ParaGard Copper T 380A intrauterine device (CuT380A) provides reversible contraception that is as effective as sterilization for up to 20 years. The CuT380A is a mainstream, first-line contraceptive option for most healthy women, including nulligravid women, as well as many women who have serious medical problems. Because it is the most cost-effective method of birth control, the CuT380A is the preferred IUD, except for women who desire lighter or no menstrual blood loss. Surveys reveal that 95% of US CuT380A users are “very” or “somewhat” satisfied with their method. This article describes current candidates for IUD use, discusses the mechanisms of action of the CuT380A, provides guidance to reduce barriers to IUD access, suggests counseling points for patients, and outlines techniques to reduce the risks and side effects that can be associated with use of the CuT380A.

Long-term safety, efficacy, and patient acceptability of the intrauterine Copper T-380A contraceptive device

The intrauterine device (IUD), primarily in the form of the copper IUD, is used by more than 150 million women around the world, making it the most widely used reversible method of contraception. With a remarkably low failure rate of less than 1 per 100 women in the first year of use, the Copper T-380A is in the top tier of contraceptives in terms of efficacy. Risks of utilization include perforation and an increased risk of infection in the first 20 days following insertion. Overall, the number of adverse events is low, making the Copper T-380A a very safe contraceptive method. The most common reasons for the discontinuation of this method are menstrual bleeding and dysmenorrhea. However, cumulative discontinuation rates of Copper T-380A are lower than that have been reported for other methods, indicating that the Copper T-380A is highly acceptable to women. After 5 years, approximately 50% of all women, who have a Copper T-380A inserted, will continue to use this highly effective contraceptive method.

Contraceptive counseling for orthodox Jewish women

OBJECTIVES

The evaluation of birth control issues among orthodox Jews who strictly follow the Halachah (the Jewish codes of conduct).

METHODS

We examine traditional Jewish concepts and practices of reproduction, review various contraceptive methods, and define problems that may arise with their use in the Jewish orthodox society. We focus on the orthodox and ultra-orthodox (Haredi) elements of the Jewish community.

RESULTS

The choices of orthodox religious women are limited and determined largely by considerations related to religious doctrine.

CONCLUSIONS

Understanding the religious, social and cultural background of patients, religious orthodox women in particular, enables to appropriately counsel them.

Blood, men and tears: keeping IUDs in place in Bangladesh

The Intra-Uterine Device (IUD) is an effective method of contraception, but in Bangladesh is associated with high levels of discontinuation within the first year. This study involved data collection from a retrospective cohort of women who had an IUD inserted 12 months earlier. In the cohort, 330 women were interviewed to identify factors associated with discontinuation. Later, 20 women, of the 103 who reported discontinuing because of excessive menstrual bleeding, were interviewed again and in depth about these issues. Of 330 women who had an IUD inserted, 47.3% had discontinued use one year post-insertion. In univariate and multivariate analyses, IUD discontinuation was strongly associated with side-effects (heavier periods; abdominal pain) and spousal factors (not discussing IUD with husband pre-insertion), but not with service delivery factors. In-depth interviews with women who reported excessive blood loss as the main reason for discontinuation found a doubling of both menstrual days and blood loss after IUD insertion. In Bangladesh, women cannot pray, have sexual intercourse, perform household tasks or participate in community activities during menstruation. Thus, women with menstrual side-effects faced serious physical, social and psychological challenges that made continuation difficult. Among those who discontinued, spouses were generally unsupportive and sometimes abusive, particularly when not involved in the decision to use the IUD.

Evaluation of iron deficiency in young women in relation to oral contraceptive use

BACKGROUND

The purpose of this study was to identify the optimal measures for diagnosing iron deficiency (ID) in oral contraceptive (OC) users and nonusers, and to estimate ID frequency in relation to OC use.

STUDY DESIGN

Conventional biomarkers of iron status - serum ferritin, iron, transferrin (Tf) and transferrin saturation (TfS) - were compared with serum soluble Tf receptor (sTfR) and the sTfR/log ferritin ratio (sTfR-F index). Two hundred two healthy menstruating white Italian women (aged 24+/-4.8 years) were analyzed. Serum ferritin concentrations <12 microg/L were considered as ID.

RESULTS

ID was detected in 29.7% (60/202) of the study women. Fifty-nine women were OC users (59/202, 29.2%). OC use did not significantly affect ID prevalence (p=.24). However, OC use markedly increased Tf in OC users, who had an odds ratio (OR) of 9.3 (CI 3.8-22.7, p<.001) for elevated Tf >330 mg/dL. No other iron status measure was affected by OC. Of the markers for ID adjunctive to ferritin, an elevated sTfR-F index >or =1.5 showed the best performance. Specifically in OC users, the elevated sTfR-F index had better sensitivity (81.0% vs. 33.3%), specificity (94.7% vs. 92.1%), efficiency (89.8% vs. 71.2%), positive predictive value (89.5% vs. 70.0%) and negative predictive value (90.0% vs. 71.1%) than a TfS <15%. Additionally, the sTfR-F index allowed the identification of low iron stores in 4.5% (9/202) of women with ferritin > or =12 microg/L.

CONCLUSION

Among healthy OC users and non-OC users, the sTfR-F index had the highest performance for diagnosing ID compared with other serum markers adjunctive to ferritin measurements, whereas sTfR by itself had a low sensitivity. We showed that neither the sTfR nor sTfR-F index was affected by third-generation OC use. The sTfR measurement is useful in the diagnosis of ID, especially in women using OC, where Tf and TfS tests may be misleading.

Copper IUD and LNG IUS compared with tubal occlusion

This article will cover current contraceptive use around the world, then examine the advantages and disadvantages of female sterilization, the hormonal intrauterine system and the copper intrauterine device. Finally, the need for contraceptive choice will be discussed along with a discussion on the cost-effectiveness of these methods.

Impact of menstrual blood loss and diet on iron deficiency among women in the UK

Women of childbearing age are at risk of Fe deficiency if insufficient dietary Fe is available to replace menstrual and other Fe losses. Haem Fe represents 10–15 % of dietary Fe intake in meat-rich diets but may contribute 40 % of the total absorbed Fe. The aim of the present study was to determine the relative effects of type of diet and menstrual Fe loss on Fe status in women. Ninety healthy premenopausal women were recruited according to their habitual diet: red meat, poultry/fish or lacto-ovo-vegetarian. Intake of Fe was determined by analysing 7 d duplicate diets, and menstrual Fe loss was measured using the alkaline haematin method. A substantial proportion of women (60 % red meat, 40 % lacto-ovo-vegetarian, 20 % poultry/fish) had low Fe stores (serum ferritin <10 μg/l), but the median serum ferritin concentration was significantly lower in the red meat group (6·8 μg/l (interquartile range 3·3, 16·25)) than in the poultry/fish group (17·5 μg/l (interquartile range 11·3, 22·4) (P<0·01). The mean and standard deviation of dietary Fe intake were significantly different between the groups (P=0·025); the red meat group had a significantly lower intake (10·9 (sd 4·3) mg/d) than the lacto-ovo-vegetarians (14·5 (sd 5·5) mg/d), whereas that of the poultry/fish group (12·8 (sd 5·1) mg/d) was not significantly different from the other groups. There was no relationship between total Fe intake and Fe status, but menstrual Fe loss (P=0·001) and dietary group (P=0·040) were significant predictors of Fe status: poultry/fish diets were associated with higher Fe stores than lacto-ovo-vegetarian diets. Identifying individuals with high menstrual losses should be a key component of strategies to prevent Fe deficiency.

Non-steroidal anti-inflammatory drugs for heavy bleeding or pain associated with intrauterine-device use

BACKGROUND

Heavy bleeding and pain are the most common reasons why women discontinue IUDs. Non-steroidal anti-inflammatory drugs, which inhibit prostaglandin synthesis, have been shown to be effective in reducing menstrual bleeding and pain in women without IUDs.

OBJECTIVES

This review summarizes all randomized controlled trials studying use of nonsteroidal anti-inflammatory drugs for treatment of bleeding or pain associated with IUD use. Trials of prophylactic use of these drugs around the time of IUD insertion were also included.

SEARCH STRATEGY

We performed searches of PubMed, CENTRAL, POPLINE, EMBASE, LILACS, and CINAHL for relevant trials. We also wrote to the authors of all trials identified to seek other published or unpublished trials.

SELECTION CRITERIA

We included all randomized controlled trials in any language that tested one or more nonsteroidal anti-inflammatory drugs for treatment or prevention of bleeding or pain associated with IUD insertion or use.

DATA COLLECTION AND ANALYSIS

Two authors independently abstracted data from relevant trials, and we entered data into RevMan for analysis.

MAIN RESULTS

We found 15 trials from 10 countries; the total number of participants was 2702. Nonsteroidal anti-inflammatory drugs (naproxen, suprofen, mefenamic acid, ibuprofen, indomethacin, flufenamic acid, alclofenac, and diclofenac) were effective in reducing menstrual blood loss associated with IUD use. This held true for women with and without complaints of heavy bleeding. Similarly, these drugs were effective in reducing pain associated with IUD use. In contrast, prophylactic use of nonsteroidal anti-inflammatory drugs had mixed results; studies with ibuprofen found no effect on pain after insertion on IUD discontinuation. No important differences emerged in the one trial comparing the effect of different NSAIDs on bleeding.

AUTHORS' CONCLUSIONS

Nonsteroidal anti-inflammatory drugs reduce bleeding and pain associated with IUD use. NSAIDs should be considered first-line therapy; if NSAIDs are ineffective, tranexamic acid may be considered as second-line therapy. Prophylactic ibuprofen administration with the first six menses after insertion appears unwarranted.

[Update on contraception]

Since the introduction of hormonal contraceptives in the 1960s, great advances have been achieved in contraception. Biological effects of sexual steroids as well as risks and benefits of oral contraception are better estimated. After the development of a new hormone-containing intra-uterine system, new hormone delivery systems offer women safe and effective contraceptive options. These new options that combine high efficacy and ease of use should allow better acceptance and compliance than daily pill ingestion and should then reduce the high rate of unintended pregnancies terminated by elective abortion. Transdermal contraceptive system and vaginal ring offer a promising innovative approach in pregnancy prevention. Subdermal implants give women the choice of a highly effective contraceptive system in spite of significant side effects. New hormonal delivery systems such as injectables are under development. Hysteroscopic tubal sterilization is now also available and is a very effective procedure. This wide variety of new contraceptive methods offers a marked improvement from previous medications for users by providing better efficacy and tolerability.

[Degradation of copper IUDs in utero. The process of metallic corrosion. A scanning electron microscope study]

OBJECTIVE

The present investigation was carried out in order to study the process of metallic corrosion of copper IUD's in utero, to precise its dynamics and location along the IUD and to appraise the influence of eventual calcareous deposition.

MATERIAL AND METHODS

A total of 461 copper IUDs representing four standard models were screened by means of optical microscopy. Especially typical samples were studied at higher magnifications under the scanning electron microscope. The obtained data were considered in terms of statistics.

RESULTS

It was possible to demonstrate a preferential corrosive activity in the lower part of the IUD without significant variations between the models. It was also possible to precise the steps of the process, to describe its most characteristic aspects and to study the eventual effect of severe calcareous deposition on corroded copper.

DISCUSSION AND CONCLUSIONS

Intrauterine copper corrosion is a normal process which occurs preferentially in the cervical portion of an IUD and can lead to the total metal loss. Both its initiation and evolution are submitted to strong individual variations. Thick and compact vaterite deposits may thwart copper erosion in case of drastic and rapid deposition.

Acceptability of the levonorgestrel-releasing intrauterine system after discontinuation of previous contraception: results of a French clinical study in women aged 35 to 45 years

This open, noncomparative study evaluated the rate of premature removals of the levonorgestrel-releasing intrauterine system (LNG-IUS) Mirena because of adverse events. To take part in the study, women had to be aged between 35 years and 45 years, and had to change their contraception for poor compliance, poor tolerance, or unfavorable change in the benefit/risk ratio of their previous contraception (oral contraceptives or copper- or progestin-releasing intrauterine device). One removal of Mirena for a wish for pregnancy was excluded from analyses, so that there were 23 removals among 203 women included. The survival ratio was 88.7%, which corresponds to a 1-year rate of premature removals of 11.3%. No statistically significant difference was found between women switched from IUD and women switched from oral contraception regarding the continuation rate (p = 0.640, log-rank test) and the discontinuation rate (p = 0.430, chi(2) test). The main reasons for premature removal were bleeding problems (11 subjects including 2 amenorrhea, 5.4%), pain (5 subjects, 2.5%), and acne (2 subjects, 1%). Two premature discontinuations occurred after accidental removal. The number of bleeding or spotting days significantly decreased from baseline (p < 0.001), and gynecological symptoms were alleviated. Hematocrit, hemoglobin levels, and serum ferritin increased significantly. No pregnancies occurred. Acne and irregular bleedings were the most frequent adverse events. The results show the excellent acceptability as well as the favorable efficacy/safety ratio of the LNG-IUS Mirena in older reproductive age women whatever the primary method of contraception.